Objectives: Clinical guidelines for the acute management of emergency department patients with severe sepsis encourage the placement of central venous catheters. Data examining the timing of central venous catheter insertion among critically ill patients admitted from the emergency department are limited. We examined the hypothesis that prompt central venous catheter insertion during hospitalization among patients admitted from the emergency department acts as a surrogate marker for early aggressive care in the management of critically ill patients.
Design: Retrospective cross-sectional analysis of emergency department visits using 2003–2006 discharge data from California, State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.
Setting: General medical or general surgical hospitals (n = 310).
Patients: Patient hospitalizations beginning in the emergency department with the two most common diagnoses associated with central venous catheter (sepsis and respiratory arrest).
Measurements and Main Results: We identified the occurrence and timing of central venous catheter using International Classification of Diseases, 9th Revision, Clinical Modifications procedure codes. The primary outcomes measured were annual central venous catheters per 1,000 hospitalizations that began in the emergency department occurring emergently (procedure day 0), urgently (procedure day 1–2), or late (procedure day 3 or later). A total of 129,288 hospital discharges had evidence of central venous catheter. In 2003, 5,759 central venous catheters were placed emergently compared with 10,469 in 2006. The rate of emergent central venous catheter/1,000 increased annually from 228 in 2003, 239 in 2004, 257 in 2005, up to 269 in 2006. Urgent and late central venous catheter rates trended down (p < 0.001). In a multilevel model, the odds of undergoing emergent central venous catheter relative to 2003 increased annually: 1.08 (95% CI, 1.03–1.12) in 2004, 1.19 (95% CI, 1.14–1.23) in 2005, and 1.28 (95% CI, 1.23–1.33) in 2006.
Conclusions: Central venous catheters are inserted earlier and more frequently among critically ill patients admitted from the emergency department. Earlier central venous catheter insertion may require systematic changes to meet increasing utilization and enhanced mechanisms to measure central venous catheter outcomes.
1Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO.
2Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO.
3Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
* See also p. 735.
This work was performed at Washington University School of Medicine in St. Louis.
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Supported, in part, by the Center for Administrative Data Research at Washington University School of Medicine and the Clinical and Translational Science Award program of the National Center for Research Resources at the National Institutes of Health (UL1 RR024992).
Dr. Theodoro received grant support from the Agency of Healthcare Research and Quality (AHRQ) (K08 HS18092). Drs. Theodoro, Owens, Olsen, and Fraser received support for article research from the National Institutes of Health (NIH) and the AHRQ. Dr. Olsen’s institution received grant support from the AHRQ (1R24 HS19455), the NIH (UL1 TR000448), Sanofi Pasteur, and Optimer. Dr. Olsen consulted for Sanofi Pasteur. Dr. Fraser’s institution received grant support from the AHRQ (5K12RR023249), the NIH, and the Centers for Disease Control and Prevention. Dr. Fraser consulted for Battelle and The Foundation for Barnes-Jewish Hospital. Dr. Fraser is employed by Washington University in St. Louis.
Address requests for reprints to: Daniel Theodoro, MD, MSCI, Division of Emergency Medicine, Box 8072, 660 S. Euclid Blvd., Washington University School of Medicine, St. Louis, MO 63110. E-mail: email@example.com